Wednesday, May 09, 2012

I try to remain mindful
and grateful, but some days I really fail. I stuck Wyatt like a pig the other
day trying out a new kind of infusion needle. Instead of being compassionate, I
was angry because things didn't go as we hoped.

I have been lucky that my few bouts of depression have been very short-lived and not frequent. I realize, though, that anxiety and anger and depression are close relations.

I think seeing this
article makes me feel better about spending some hard earned cash on a
family adventure this year. A change of scenery and a change of routine will do us good.

Like many other primary
care doctors, I sometimes sense the shadow of depression hovering at the edges
of the exam room. I am haunted by one mother with severe postnatal depression.
Years ago, I took proper care of the baby, but I missed the mother’s distress,
as did everyone else.

Nowadays it’s
increasingly clear that pediatricians, obstetrician-gynecologists and
internists must be more alert. Research into postnatal depression in particular
has underscored the importance of checking up on parents’mental health in the
first months of a baby’s life.

But a parent’s
depression, it turns out, can be linked to all kinds of problems, even in the
lives of older children.

“Depression is an
illness that feeds upon itself,” said Dr. William Beardslee, professor of child
psychiatry at Harvard Medical School, who has spent his career studying
depression in children and developing family interventions. “Very often people
who are depressed don’t seek the care they need.”

In 2009, the Institute
of Medicine and the National Research Council issued a report, “Depression in
Parents, Parenting, and Children,” that summarized a large and growing body of
research on the ways that parental depression can affect how people take care of
their children, and how those children fare.

One in five Americans
will suffer from depression at some point, noted Dr. Beardslee, who was on the
committee that issued the report. “Untreated, unrecognized parental depression
can lead to negative consequences for kids,” he said, ranging from poor school
performance to increased visits to the emergency room to poorer peer
relationships and adolescent depression.

Moreover, there is
plenty of evidence that when depressed parents get treatment and help with their
parenting, families are much better off.

Depression is certainly
treatable, said Dr. Mary Jane England, a psychiatrist and professor of health
policy and management at Boston University School of Public Health, who led the
Institute of Medicine committee.

But, she added, “because
of stigma and lack of training of some of our primary care practitioners, we
don’t pick it up.”

Depression damages the
interactions between parents and children, and disrupts family routines and
rituals. Children with a depressed parent are themselves more likely to
manifest symptoms of depression, research shows, along with other psychiatric
problems and behavior issues. They are more likely to make visits to the
emergency room and more likely to be injured.

A depressed parent may
have trouble following a plan of preventive care if a child has a medical
problem like asthma. But higher rates of depression in parents whose children
have chronic medical problems may also reflect the stress of dealing with those
problems, especially for psychologically vulnerable parents.

Depression may become
part of a vicious cycle in these families: An overwhelmed and depressed parent
is less able to follow a complex medical regimen, and a child ends up in the
emergency room or the hospital, creating more pressure and more stress for the
family.

“There is a high burden
of maternal depression, anxiety,” among mothers bringing children to an
emergency room, said Dr. Jacqueline M. Grupp-Phelan, a pediatric emergency room
specialist at Cincinnati Children’s Hospital. “It influences their own
perception of how well they can deal with their kids’ problems.”

It’s also become clear
that there may be genetic propensities to depression. Its appearance in parent
and child may in part reflect inherited vulnerabilities.

And all of that
reaffirms how critical it is for primary care doctors to ask the right
questions and offer diagnosis without stigma.

“Moms appreciate being
asked,” said Dr. Grupp-Phelan, who has done research on the acceptability of
mental health screening. “It may be the only time they’ve been asked about
their depression.”

I often find myself
urging mothers to pay more attention to their own medical problems and mental health.
Pediatric colleagues tell stories of depressed parents who break down and cry
during a child’s visit, but then say they’re too busy taking care of the family
to get help for themselves.

I don’t love the “do it
for your child’s sake” argument; I worry it suggests that the parent isn’t
important in her own right. But to be honest, I make that argument anyway,
because it works.

“They are open to doing
something about their own issues because it could help their kid, and that’s a
very strong hook for mothers,” Dr. Grupp-Phelan said. And when the “doing
something” includes a focus on the whole family, those routines and rituals and
routines can be rebuilt, and there’s plenty of research to show that children
are resilient.

So if parents are open
to being asked, and if we know that identifying depression has important
benefits for our patients and their parents, why aren’t we better at asking?

As a pediatrician, I
tend to focus on the child, of course. Asking mental health questions of the
parent can sometimes feel intrusive or invasive.

And there’s the worry
that even if you identify a problem, there may not be good help available. When
poverty and lack of access are combined with parental depression, not
surprisingly, the risks are that much greater.

And in looking for
parental depression, in asking about it and discussing the risks, there may be
a sense that doctors are placing blame. I think we fear that parents who are
struggling with these shadows will feel accused and inadequate.

“The last thing in the
world we should be doing is blaming parents,” Dr. Beardslee said. “We should be
reaching out and offering hope.”

What's the weather like here?

Tomatohead's bits

Now that I live in the middle of the desert, I get positively weepy when I think about Asian noodle dishes. Other than that, life is good. We chug along as a family surrounded by a wonderful community of friends - near and far. We rock out when the odd band graces us with their presence. We potluck all the time. We like our espresso, beer, whisky, cured pork products, and chocolate.